Corporate

December 26, 2018

Level of Appeals

CGS handles the first level of appeal, Redeterminations. Recently, we have noticed an increase in the number of initial appeal requests sent as a Reconsideration before a Redetermination has been requested. When appealing our claim decisions, please keep in mind that you must go through the appeal levels in order, starting with a Redetermination.

After we process your claims, physicians, suppliers, and people with Medicare have the right to appeal our claim determinations. Appeals activities conducted by us are governed by the Centers for Medicare & Medicaid Services (CMS).

There are five levels of appeal. They are as follows:

Level Type of Appeal Time Limit for Filing Request Monetary Threshold to be Met
1 Redetermination 120 days from the date of receipt of the notice of initial determination None
2 Reconsideration 180 days from the date of receipt of the redetermination. NOTE: If a party requests QIC review of a contractor's dismissal of a request for redetermination, the time limit for filing a request for reconsideration is 60 days from the date of receipt of the contractor's dismissal notice. None
3 Administrative Law Judge (ALJ) Hearing 60 days from the date of receipt of the reconsideration Current Amount in Controversy (AIC) requirements can be found on the CMS websiteExternal PDF. See §250 for additional information.
4 Departmental Appeals Board (DAB) Review/Appeals Council 60 days from the date of receipt of the ALJ hearing decision None
5 Federal Court Review 60 days from date of receipt of the Appeals Council decision Current AIC requirement can be found on the CMS websiteExternal Website. See §345 for additional information.

Please refer to the Medicare Claims Processing Manual, Pub. 100-04, Chapter 29 – Appeals and Claims DecisionsExternal PDF and the Original Medicare (Fee-for-service) AppealsExternal Website Web page for additional information.

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